Multiple myeloma is a cancer of the bone marrow plasma cells. It is synonymous with "myeloma" and "plasma cell myeloma." Plasma cells make antibodies against infectious agents such as viruses and bacteria. A cancerous or malignant plasma cell is called a myeloma cell. Myeloma is called “multiple” because there are frequently multiple patches or areas in bone marrow where it grows.

Farydak (panobinostat)

Farydak is a prescription medication taken in combination with Velcade and dexamethasone to treat patients with multiple myeloma who have already been treated with Velcade and an immunomodulatory drug. Immune modulators include Thalomid® (thalidomide), Revlimid® (lenalidomide), and Pomalyst® (pomalidomide, known in Europe as Imnovid®). Farydak is the first histone deacetylase (HDAC) inhibitor approved for use in treating MM

How Does It Work?

Farydak interferes with myeloma cells' ability to clear waste proteins and reproduce. Unlike most healthy cells in the body, myeloma cells are particularly vulnerable to the build-up of waste proteins. When overwhelmed by waste proteins that cannot be cleared or recycled, myeloma cells will die. Velcade also interferes with the removal of waste proteins in myeloma cells. The combination of Velcade and Farydak, boosted by the effects of the powerful steroid dexamethasone, is more effective than any of those drugs alone.

Side Effects of Farydak, Velcade, and dexamethasone

Two of Farydak's potential side effects are serious enough to warrant a "boxed warning" on the prescribing information because they are potentially life-threatening:

severe diarrhea

cardiac toxicities (heart problems)

Possible Side Effects

Diarrhea

Diarrhea is defined as three or more loose stools per day. It is common with Farydak and may be severe (defined as 7 or more stools per day requiring treatment with intravenous fluids or hospitalization). Tell your healthcare provider right away if you have stomach cramps, loose stool, frequent bowel movements, or if you feel like you’re becoming dehydrated. Thirst and dark-colored urine are early symptoms of dehydration.

Heart problems

Farydak can cause severe heart problems, which can lead to death. Your risk of heart problems may be increased if you have a pre-existing condition called “long QT syndrome,” a heart rhythm condition that can potentially cause fast, chaotic heartbeats, or if you have other heart problems.

Severe bleeding (from low platelet count)

Farydak can cause severe bleeding (hemorrhage), which can lead to death. It may take longer than normal to stop bleeding while you are taking Farydak.

Fatigue

Fatigue is commonly associated with cancer and with cancer therapy. Caution is advised if you are operating machinery, including driving a car. For more detailed information, please read the IMF publication UnderstandingFatigue.

Nausea and vomiting

In the clinical trial leading to its approval (PANORAMA-1), Farydak patients experienced nausea, 6% of which was serious enough to require hospitalization, while 26% of patients experienced vomiting, 7% of which was serious enough to require hospitalization or urgent intervention.

Peripheral edema

Peripheral edema is accumulation of fluid that causes swelling, usually in the ankles, feet, and legs. This swelling is the result of the accumulation of excess fluid under the skin in the spaces within the tissues, or “interstitial” spaces. Peripheral edema can be a side effect of long-term use of anti-inflammatory medications (such as the corticosteroid dexamethasone), which increase fluid pressure from sodium and water retention, and thereby upset the balance of inflow and drainage of interstitial fluid. Peripheral edema can also result from many other causes, including immobility, obesity, varicose veins, cardiac, kidney, or liver dysfunction, gastrointestinal disorders, medications for diabetes such as insulin and pioglitazone, and non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and naproxen. Usually, peripheral edema affects both of the legs, ankles, and/or feet. If you have swelling in one leg only, you should tell your healthcare team immediately, as it might signal the presence of a blood clot.

Decreased appetite

There are many causes for loss of appetite during treatment with FVD, including other side effects of treatment such as diarrhea and nausea. Lack of exercise, anxiety, depression, and pain can also contribute to the problem. Good communication with your healthcare team members will help them understand how you’re feeling physically and mentally, and will help determine the source of your appetite loss.

Fever

Fever can be the sign of a bacterial or viral infection, an adverse reaction to a drug or, in rare cases, an aggressive myeloma relapse. Since fever could be the sign of a life-threatening condition, you should report the problem to your healthcare provider immediately.

Low white blood cell count

White blood cells constitute the immune system, the body’s defense against infection. When the WBC count is low, the body’s normal defenses against viral, bacterial, and fungal infections are reduced. Both Farydak and Velcade can lower the WBC count, while dexamethasone prevents the remaining white cells from reaching the sites of infected tissues. Each of these drugs can contribute to an increased risk of infection. The addition of Farydak to Velcade and dexamethasone caused almost twice as much reduction in WBC count in the PANORAMA-1 trial than occurred in the control arm of the study.

Low red blood cell count (anemia)

Red blood cells (RBCs) contain hemoglobin, a protein that contains iron and transports oxygen from the lungs to the body’s organs and tissues. When a patient has anemia, the result is low levels of oxygen in the body, which may cause shortness of breath, paleness, and feelings of exhaustion. 62% of the patients in the Farydak arm of the PANORAMA-1 study developed anemia, as compared to 52% in the placebo arm.

Electrolyte abnormalities

Electrolytes (which include sodium, potassium, calcium, magnesium, chloride, and phosphorus) are electrically charged substances in the blood and other fluids that are involved in such important functions as regulating the amount of water in the body, the acidity of the blood, nerve and muscle function (including the heart muscle), and other important processes. Electrolyte abnormalities can be caused by poor intake of fluid or food (loss of appetite), by loss of body fluid (vomiting or diarrhea), or by kidney disease (as evidenced by increasing creatinine levels).

Increased creatinine

Increased creatinine is a sign that the kidneys are not working properly. Creatinine is the biproduct of normal muscle break-down, and it is secreted by the kidneys into the urine. When the kidneys are impaired, the amount of creatinine in the blood increases. The kidneys may function poorly because of myeloma light chain deposits in the tubules of the kidney, or because of the effects of treatment related to hydration, or both. Among the treatment-related reasons for increased creatinine are other side effects such as loose watery stool, vomiting, loss of appetite, and dehydration.